What is the best insulin treatment option for a patient with type 2 diabetes and no insurance?

Best Insulin Treatment for Uninsured Patients with Type 2 Diabetes

For patients with type 2 diabetes and no insurance, human NPH insulin combined with metformin is the most cost-effective and appropriate initial insulin regimen. 1

Cost Considerations Drive Treatment Selection

Human insulin (NPH and regular) can be purchased for considerably less than analog insulins at select pharmacies, making it the appropriate choice for individuals with cost concerns. 1 The World Health Organization strongly recommends human insulin for managing blood glucose in adults with type 2 diabetes in low-resource settings, as the relatively modest overall benefit from insulin analogs is outweighed by the large price difference. 1

NPH insulin costs approximately $165 per 1,000 units (U-100 vial), while long-acting analogs like glargine cost $165-$341 per 1,000 units depending on the formulation. 1 Human regular insulin and NPH 70/30 premixed products are available at even lower prices at select pharmacies. 1

Initiating NPH Insulin Therapy

Starting Dose and Administration

• Begin with 10 units of NPH insulin once daily at bedtime, or use weight-based dosing of 0.1-0.2 units/kg/day. 1, 2
• Continue metformin unless contraindicated, as this combination decreases weight gain, lowers insulin dose requirements, and reduces hypoglycemia compared to insulin alone. 1, 3
• If the patient was on a sulfonylurea, discontinue it when starting insulin to prevent hypoglycemia. 2

Titration Protocol

• Increase NPH by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL. 1, 2
• Target fasting plasma glucose of 80-130 mg/dL. 1, 2
• If hypoglycemia occurs, reduce the dose by 10-20% immediately. 2

When to Advance Beyond Basal NPH

If after 3-6 months the fasting glucose is controlled but HbA1c remains above target, postprandial hyperglycemia requires additional coverage. 2, 4 At this point:

Option 1: Add Regular Human Insulin Before Meals

• Start with 4 units of regular human insulin 30 minutes before the largest meal. 1, 4
• Regular human insulin is acceptable and considerably less expensive than rapid-acting analogs, though it requires administration 30 minutes before meals rather than immediately before eating. 1, 4
• Titrate by 1-2 units every 3 days based on postprandial glucose readings. 2

Option 2: Switch to Premixed NPH/Regular 70/30

• Administer twice daily (before breakfast and dinner), starting with total daily dose split equally. 5, 6
• This provides both basal and prandial coverage in a single injection, improving adherence for patients who struggle with multiple daily injections. 5
• Studies show once-daily premixed insulin 70/30 before dinner combined with metformin reduces HbA1c by 1.1-1.3% in patients previously uncontrolled on oral agents. 5

Critical Advantages of Human Insulin for Uninsured Patients

While long-acting analogs (glargine, detemir) modestly reduce nocturnal hypoglycemia compared to NPH, these advantages are small and may not persist over time. 1 For individuals with:

• Relaxed HbA1c goals
• Low rates of hypoglycemia
• Prominent insulin resistance
• Cost concerns

Human insulin (NPH and regular) is explicitly recommended as the appropriate choice. 1

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications, as this prolongs exposure to hyperglycemia. 2
• Do not continue escalating NPH beyond 0.5 units/kg/day without adding prandial coverage, as this causes overbasalization with increased hypoglycemia risk. 2, 7
• Do not abruptly discontinue metformin when starting insulin—continue it unless contraindicated. 1, 3
• Ensure proper patient education on insulin injection technique, site rotation, hypoglycemia recognition and treatment, and "sick day" rules. 1, 2

Alternative Low-Cost Options

If NPH causes problematic nocturnal hypoglycemia despite dose adjustments, consider:

• Follow-on biologics for insulin glargine or generic versions of analog insulins, which may expand cost-effective options. 1
• Patient assistance programs from manufacturers, though availability varies.

The key principle: For uninsured patients with type 2 diabetes, clinicians should be familiar with human insulin use, as it remains the most cost-effective option that can achieve glycemic targets when properly titrated. 1

Human insulin has been used successfully for decades, and the modest benefits of analogs do not justify their substantially higher cost for most uninsured patients. 1 The priority is ensuring patients can afford and adhere to their insulin regimen rather than prescribing more expensive formulations they cannot sustain. 1